New York Health Equity Reform (NYHER)

1115 Waiver Amendment Request FAQ

  • FAQs also available in Portable Document Format (PDF)

The following summarizes and addresses questions as part of the public comments received by the New York State (NYS) Department of Health (DOH) in response to the NYHER 1115 Waiver Amendment Application, as part of the public comment process.

Q: What types of entities will participate in the HERO?

A: NYS revised the final application to include additional stakeholders and clarified that the lists within the application are only illustrative and HERO composition will not be limited to what was expressed in the application.

HERO composition will include, but not be limited to:

  • Medicaid managed care organizations (MCOs),
  • Local health departments,
  • Hospitals and health systems,
  • Community-based providers (including primary care providers),
  • Providers serving children and families with complex needs including behavioral health-related needs,
  • Population health vehicles such as accountable care organizations (ACOs) and independent provider associations (IPAs) including behavioral health IPAs,
  • Behavioral health networks,
  • Providers of long-term services and supports (LTSS) including those who serve individuals with I/DD or physical disabilities and nursing homes,
  • Community-based organizations (CBOs) organized through Social Determinant of Health Networks (SDHNs),
  • Qualified Entities (QEs), including Health Information Exchanges (HIEs) and Regional Health Information Organizations (RHIOs),
  • Tribal Nation representatives, and
  • Consumer representatives including those with lived experience of severe mental illness (SMI), substance use disorder (SUD), physical, intellectual, and developmental disabilities, as well as those who serve these populations.

Q: Will NYS allow for flexibility within the HERO structure?

A: There is a high degree of flexibility built into the HERO structure to allow HEROs to address the array of regional needs, including those that differ by population, type of health disparity, geography (i.e., urban vs. rural) or other distinctions.

Q: Will NYS consider composing HEROs with a majority of community-based organizations (CBOs) compared to other stakeholders or have strong consumer representation?

A: CBO and consumer participation in HEROs is important to provide valuable insight into the needs of each region and community members’ lived experiences. The HERO procurement would include requirements for an inclusive governance body with balanced stakeholder decision-making authority. While HERO membership already incorporates consumer representation, we have clarified the illustrative HERO composition list to include consumers with lived experience, including individuals with SMI, SUD, and physical, intellectual, and developmental disabilities.

Q: Will NYS use the waiver amendment to invest in children’s mental health or invest in children and families?

A: Yes. In the final waiver amendment application, we have more explicitly referenced children and families throughout the waiver. The amendment provides significant opportunity for investment in services and supports for children and families.

Q: Will community-based organizations (CBOs) that operate in more than one region be allowed to contract with multiple SDHNs?

A: CBOs who operate in more than one geographic area will not be limited to participation in only one SDHN.

Q: Limiting the SDHNs to evidence-based interventions is too restrictive. Will NYS consider allowing payment for interventions based on promising practices?

A: NYS believes there may be instances where an intervention based on promising practices rather than an evidence-based standard could be appropriate and will work with CMS to enable DOH to approve additional interventions on a pilot basis within the regions.

Q: Will NYS increase funding allocated to SDHNs? We are concerned that it is not enough to support CBO participation in the amendment activities.

A: In the final waiver amendment application, we have increased funding for the SDHNs by $69 million per year. We believe the additional funding will assist in building capacity and preparing CBOs to participate in the SDHNs, as well as provide targeted interventions to Medicaid enrollees once the networks are functional.

Q: What is the State’s vision for the social care needs referral and data platform?

A: We have updated the Social Care Date Interoperability Exchange section in the final application waiver amendment application to reflect that the State will set forth requirements and standards for SDNH social care platforms that leverage the existing statewide health information technology. Referral and social care needs data will feed into a statewide data repository supported by the existing infrastructure of the Statewide Health Information Network for New York (SHIN-NY). Data systems that support screening and referral processes will be qualified and approved by the State to ensure interoperability. This will ensure interoperability, standardization, and timely data sharing, while also allowing for flexibility.

Q: Will the State standardize data elements but not require a single social care needs assessment tool?

A: NYS will assess validated social needs assessment tools and will select one tool that allows for data interoperability on a regional and statewide basis. Using a single assessment tool will enable reliable and meaningful statewide data comparison and measurement.

Q: Will developmental screenings be covered and provided by community partners in the SDHNs?

A: Medicaid recently added coverage for early childhood global development screening and autism screening as separate, reimbursable services in the primary care setting. Based on needs assessments findings, HEROs could advance additional screening through community partners in regions where the populations and delivery system demonstrate need.

Q: Will the waiver amendment explicitly address food insecurity interventions?

A: Food insecurity is often reported as the number one social care need identified among Medicaid members. NYS is prioritizing a range of social care needs in the waiver amendment, including food insecurity. The nature, design, and scope of food insecurity intervention will be led by the regional SDHN, with input from community stakeholders.

Q: Will the waiver amendment include transportation services?

A: Transportation is a social need that will be addressed by the SDHNs.

Q: Will the global prepayment model be introduced in every region?

A: Each HERO will develop its own regional plan, based on stakeholder and community engagement and a needs assessment, and tailored to fit the needs of the region. The global prepayment model pilots would be recommended as part of those plans as applicable.

Q: How will NYS hold Medicaid managed care organizations (MCOs) accountable and require them to share data in a timely fashion?

A: DOH provides oversight for MCO contracts under requirement set forth in the Managed Care Model Contract and will continue to do so for the waiver amendment, which will include requirements for MCOs that support the policy goals of the advanced VBP arrangements. Additionally, the amendment envisions using a statewide data store supported by the existing infrastructure of the SHIN-NY to provide the near real-time insights into waiver activities such as screenings, referrals, and service outcomes. Existing and future referral platforms/data systems supporting screening and referral processes will be qualified to ensure interoperability. Leveraging these multiple approved systems, data will be shared between the SDHNs, HEROs, and for advanced VBP arrangements.

Q: How will NYS ensure CBOs are ready to participate in VBP arrangements?

A: We believe the capacity building investments (see Strategies #1.2 and #1.4 in the final application) will support CBOs in preparing to participate in the advanced VBP arrangements.

Q: How will the new waiver amendment will impact existing VBP relationships and existing relationships between MCOs and CBOs for social care needs?

A: Existing VBP relationships can continue under the waiver amendment, but it is anticipated that the VBP investments into social care will expand with the new waiver amendment and partner with SDHNs to address multiple social needs.

Q: How will NYS ensure that VBP contract requirements do not create too much risk for CBOs?

A: CBOs will be paid for services according to a fee schedule that will be established for social care needs interventions. CBOs will not enter into risk-based contracts.

Q: Does the waiver amendment application include Medicaid coverage for services prior to release from a state psychiatric hospital in addition to jail and prison settings?

A: An Institute for mental disease (IMD) is a hospital, nursing facility or other institution of more than 16 beds that is used for providing care and treatment of people with mental illness. Generally, payment for services within IMDs have been excluded in Medicaid. The Centers for Medicare and Medicaid Services released guidance in 2018 that gave states the opportunity to submit Section 1115 demonstrations to address the needs of beneficiaries with serious mental illness, including waiving the IMD exclusion. While the NYHER waiver amendment application does not seek Medicaid coverage for services prior to release from a state psychiatric hospital, NYS is pursuing this through a separate waiver amendment.

Q: The draft waiver amendment application used the terminology "psupportive housing,"p but will the State consider using "ptransitional housing"p to better describe the housing and services proposed in Strategy #2?

A: NYS agrees with this suggestion, and we have clarified in the final application that Strategy #2 provisions provide transitional housing services.

Q: Will NYS include older adults in the housing section of the waiver amendment?

A: The waiver amendment already includes older adults who are living in institutional settings, such as nursing homes and long-term care facilities.

Q: Will NYS increase investments under the housing-related strategy?

A: No. The waiver amendment application represents a $1.57 billion investment in transitional housing for high needs Medicaid enrollees over five years.

Q: Are pre-housing services included in the housing provisions?

A: Yes, we have clarified in the final application that transition services include services to prepare an individual for housing and connections to health care services.

Q: Will NYS expand the number of funded housing opportunities for homeless populations with medical, behavioral health, and social care needs?

A: The Enhanced Transitional Housing Initiative will include services to help individuals stay safely housed in the community and connection to housing for individuals experiencing homelessness, including those with medical, behavioral health, and social care needs, and individuals leaving long term institutional settings. Creating new housing is beyond the scope of this waiver amendment.

Q: Will NYS include investments in community health workers, to address the behavioral health workforce shortage, or to address critical workforce shortage areas? Will NYS include investments in human services and/or CBO staff in the waiver amendment to enable participation in VBP and waiver initiatives?

A: NYS recognizes the critical workforce shortages across all sectors of the healthcare system, which is why we have tried to create proposal that investments across the healthcare continuum. Community health workers are an important part of the workforce and key to advancing health equity, which is why we have included them in the workforce investments. We also recognize that there is shortage in the behavioral health workforce and have clarified their inclusion in recruitment and retention initiatives. The capacity building and training initiatives outlined in Strategy #1.2 and #1.4 include training investments in CBO staff to support participation in VBP and waiver initiatives, and investments in Strategy #3 to address workforce shortages and support the expansion of community health workers, care navigators and peer support workers.

Q: Will NYS use the Area Health Education Center (AHEC) system in addition to WIOs?

A: NYS anticipates that Workforce Investment Organizations (WIOs) will partner with other workforce development centers operated at the local and regional level.

Q: Will NYS include payment parity for telehealth services and/or account for a lack of broadband access for some Medicaid enrollees?

A: Payment parity for telehealth services affirms that the high-quality care provided at in-person visits is also achieved when the same service is offered via telehealth. The NYS 2023 Enacted Budget (Health and Mental Hygiene, Part V) included a provision for telehealth parity, which requires payers to reimburse telehealth services "pon the same basis, at the same rate, and to the same extent"p as services delivered in person. Certain fees (e.g., facilities fees) are excluded from this requirement when such costs are not incurred (e.g., when patient and provider are both off-site). NYS is creating additional billing guidance to address clinic telehealth billing.

Several of the initiatives under Strategy #4 of the waiver amendment application aim to bring digital health options to rural communities and other parts of the state that lack broadband access. Community health workers will be outfitted with telehealth backpacks that include the technology necessary to boost internet connectivity as well as devices needed to connect patients to healthcare providers. Additionally, NYS will furnish tablets with data plans to providers and Medicaid enrollees in areas identified as high need, including broadband deserts.

Q: Will NYS use telehealth funding to increase access to services for the I/DD population?

A: Many of the telehealth initiatives in the waiver amendment application are intended to bring care to those with I/DD and/or physical disabilities. Specialty virtual care models will be expressly designed to serve people who face accessibility barriers, such as people with long term care needs and/or people with I/DD. Funding will be used to connect homebound enrollees and those living in residential facilities with equipment and virtual care subscriptions. Collaboration with the I/DD field will be essential in designing programs and policies that meet the unique needs of the population.

Q: Will NYS unify communication and coordination of physical, behavioral, and social care across the care continuum?

A: Telehealth can be used broadly in both addressing patient’s physical, behavioral, and social care needs, and in creating digital provider networks to coordinate care for their patients. NYS intends to use digital infrastructure to identify patients that would benefit from care coordination and other supports, such as health homes. A statewide collaborative group will identify strategies for building and supporting needed digital infrastructure.

Q: How will the telehealth platform leverage proven best practices, established technology as well as breakthrough innovations?

A: The statewide collaborative will identify strategies for building and supporting needed digital infrastructure. We envision the collaborative will include experts and stakeholders representing different populations and geographies and will contribute their knowledge around best practices and innovations.

Q: Will NYS define health equity in the waiver amendment?

A: In the final application we have included the definition of health equity from the Robert Wood Johnson Foundation in the introduction.

Q: Will NYS prioritize people with I/DD or dual eligibles in the waiver amendment?

A: We have clarified in several section of the waiver where I/DD populations fit in, including as a targeted population that HEROs may focus on based on regional priorities. While not specifically named in the waiver document, NYS considers duals/older adults to be represented throughout, including in the HERO strategies in Strategy #1.1 where "providers of long-term services and supports (LTSS)" are named, in Strategy #2 "Investing in Transitional Housing Services and Alternatives for the Homeless and Long-Term Institutional Populations" whereby it will "ensure the availability of sufficient long-term services and supports and accessible health care capacity to enable aging in place," and in Strategy #3 to strengthen the workforce for LTSS.